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ICATION FOR LIQUID WASTE PERMIT SAN JO`JCOUIN COUNTY PUBLIC HEALTH SERVIC-S ENVIRONMENTAL HEALTH DIVISION j 304 EAST WEBER AVENUE, STOCKTON, CA 9520Capy(209) 468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAH FROM 0117E ISSUED / IC\mpl{t{In Trlpli{BHI APFUCATION IS HEREBY MADE TO THE BAN JOAOUIN COUNTY MR A MMM TO CONSTRUCT ANDMA INSTALL THE MAK.DE THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAGUIN COUNTY DEVELOPMENT /C.ifumi 9-1110.E THE STANDARDS OF BA/yy�,' ACON COUNTY MOM HEALTH SERVICES.EENNRONMENTK 10 HEALTH dVISN. / L <17(79 JE/��A/ / / CFrYf__ _ LOT SIZE 'Af�•` T. JOB ADDRES&OR APNf1_ -3 / ADDRESS ^/'!/i�G PHONEL/' OWNER'S NAME �T lIOM Rpm CONTRACTOR l ADDRESS ,�JJ /��,// �7/ S l P( - ./ SrK UC, 2C S P,bNE/ .moi S '•l3 SUB CONTRACTOR //l "T/-FF �/*,/ � -f"Fn- ADDRE6A� , I TYPE OF SEPTIC WORK: NEW INSil1UAlWN ❑ REPAI.ADDITIO MTR MON❑ me TFSTHI I I)IOW MANY ENO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WTTHIN 300 FEET OF 111.1911111113.1 /I ApPSutlon l INSTALLATION WILL{SNE: RESIDENCE❑ COMMERCIAL❑ OTHER LL NUMBER OF WINO UHTS:_ NUMBER OF BFE37WOMS: NUMBER OF EMF OYEEH:' 11 l }/( '/Z'dcl. WATER TABLE DEPTH �CWA-F TFR OF Wit TO A DEPTH OF J FEFT: '�'" _MMUMP Wit CHARACTEIL' —O NO.COMPARTMEHt6 FFPNC-T ))ANK/OItFA{E TMP ❑TVPEIMFEI/ S�"T/ �YU)e�4T CAPADNY �/� -PKD TREATMENT RANT❑ DISTANCE TO NEARPST: WELL r)r� A �` FOUNDATION Ic / P1bPERTY'UNE �r , UFT STATION❑ 612E TYPE OF RUMP SAND OR SEPARATOR(ENCLOSED WaTEMI LEACHING UNE ❑ NO.\IENOTH OF UNEe DISTANCE TO NFAiIESTt WELL FOUNDATION PROPERTY UNE - FILTER BFO ❑WIDTH LENOTN DEPTH DISTANCE TO NEAREST:WELL roUNDATION PROPERTY UNE MOUNDED ❑T WIDTH LENGTH DEPTHAR ��'�DISTANCE TO NEAREST:WELL FOUNDATIONPROPERTY UNE / SEEPAGE FITS /L.I DEPTH ,.�` , WE .(CI•• NUMBER J dSTAME TO NiWELL /telyFOUNDATION � 1 PROPERTY UNE BUM" I ❑WIDTH LEWTN DEPTH DISTANCE TO NEAREST:WELL PoVNDATbN RIDPERIY UNE DIiro/AL POND{ ❑WIDTN lENOTH DEPTH " DISTANCE TO NEAREST:VIELL FOUNDATION PRDPERPY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILLBE OONE IN ACCORDANCE WTH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOACUIN COU / .HOME OWN1 LICENSED AOENT'9 MONATVPEGERTIFIESTNEroLLOWNG:•ICEIRIFYTHAT IN TMEpfgFOPARNCEONTRACTORHE roRWHIOH THIS PEPMR IS ISSUED.1 BM NOT EMROV _PERSON W SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIM MA.• CONTRACTORS HIPoNO OR BUS CONTRACTING SIONATU RCEIRIFIES THE LLOWNO:'i CERTIFY THAT IN THE PERMFMANCE OF THE WORK FOR WHICH THIS PERMR IS ISSUED,I SHALL FM0.0Y PERSONS SUBJECT TO WORKMAN'S COMPENMT LI�WS OF CALI A=-THE APPMANT MUST CALL 34 HOW IN ADVANCE FOR ALL RWIBRED INSPECTIONS. COMPLETE ORAWNG BELOW. /b1� TITLE' _ DATE' - SIGNED K I' ROT PLAN WAAW TO SCALE)SCALE----*le 1, NAMES OF STREETS OP ROADS NEAREST TO OR BOUNONO THE PROPERTY. 4.EXPANSION NOF HOUSE E DISPOSAL E DISPOSALSYSTEMS SYSTEM OR PI1DroSED E%CATION Of SEWAGE DIBPoBK SYSTEMS. I. DMENOUTLINE OF THE PROPERTY.WTH LOCATION A AND NORTTING DIRECTION.'D 6. LOCATION OF WELLS DI NIH PROPER OF ONE HUNDRED FIFTY FT.ON ]. DIMENSIONED OUTLINES AND LOCATION OF ALL E)lIeTINO AND PIOro6ED STRUCTURES,' -THE PROPERTY OR ADJOINING PROPERTY. IMMOINO COVERED MFRS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. Aiva ...... fi I 1 k .. . 1 ` FOR DEPARTMENT USE ONLY /I�x DATE: Z '-.�•1 AREA: AT ICATION ACCEPTED BY _ tt 1 iL "T'!✓t:�P:' S ' 1}/ 9rl TANK,PH OR BUMP b6RCT1ON BY ✓F' DATE� l' I r'�-�FINAL mIO SPECTN SY ' DATE / ADDITIONAL COMMENTS. ACC UXTI O ONLY: AD FAG PE CODE FEE INTO AMOUNT MAI 10 llEOKIICASH PFCDVm SY DATE SR/PDRMIT NUMBER INVOICE I cl (-• I � Put.HeaRh Selo. EnvirO. 174(3/96)